HUD-92205-OHF Borrower's Certificate of Known Costs (Section 242/223f)

Borrower’s Certificate of Known Costs Section 242/223f

U.S. Department of Housing and Urban Development Office of Hospital Facilities

OMB Approval No. 2502-0602 (Exp. 08/31/2019)

Public reporting burden for this collection of information is estimated to average 4 hours. This includes the time for collecting, reviewing, and reporting the data. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Reports Management Officer, QDAM, U.S. Department of Housing and Urban Development, Washington, DC 20410-5000. Do not send this completed form to the above address. The information requested is required to obtain the benefit under Section 242 of the National Housing Act. No confidentiality is assured. The information is being collected to obtain the supportive documentation that must be submitted to HUD for approval and is necessary to ensure that viable projects are developed and maintained. The Department will use this information to determine if properties meet HUD requirements with respect to development, operation and/or asset management, as well as ensuring the continued marketability of the properties. This agency may not collect this information, and you are not required to complete this form unless it displays a currently valid OMB control number. 

Warning: Federal law provides that anyone who knowingly or willfully submits (or causes to submit) a document containing any false, fictitious, misleading, or fraudulent statement/certification or entry may be criminally prosecuted and may incur civil administrative liability. Penalties upon conviction can include a fine and imprisonment, as provided pursuant to applicable law, which includes, but is not limited to, 18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802; 24 C.F.R. Parts 25, 28 and 30, and 2 C.F.R. Parts 180 and 2424.

To: Secretary of Housing and Urban Development Office of Healthcare Programs Office of Hospital Facilities Attn:      		FHA Project Number:      
		Project Name:      
		Location:      
The actual cost to the undersigned of labor, materials and necessary services for the purchase/ or refinancing of the existing properly (land and improvements) in connection with the subject loan, after excluding any kickbacks, rebates, adjustments made or to be made is as follows (attach supporting documents):
Item	Paid		To be Paid at Endorsement	Total
Purchase Price or Existing Indebtedness	$     		$     	$     
Limited Rehabilitation (Itemized on Schedule A of this form)	$     		$     	$     
HUD Fees	$     		$     	$     
Lender’s Fees (Loan origination and closing)	$     		$     	$     
Recording Expenses	$     		$     	$     
Legal and Organizational Expenses	$     		$     	$     
Other Expenses (Itemized on Schedule C of this form)	$     		$     	$     
Total Cost	$     		$     	$     
This certification is made, presented and delivered under penalty of perjury for the purpose of influencing and official action on behalf of the Secretary of Housing and Urban Development. This certification may be relied upon as a true statement of the facts contained herein.
Signature of Borrower:	Date:      
Warning: U.S. Code, Title 31, Section 3729, False Claims, provides a civil penalty of not less than $5,000 and not more than $10,000, plus 3 times the amount of damages for any person who knowingly presents, or causes to be presented, a false or fraudulent claim; or who knowingly makes, uses, or causes to be used, a false record or statement; or conspires to defraud the Government by getting a false or fraudulent claim allowed or paid.
Warning: U.S. Criminal Code, Section 1010, Title 18, HUD and Federal Housing Administration transactions, provides in part: “Whoever, for the purpose of…influencing in any way the action of such Department…makes, passes, utters, or publishes any statement, knowing the same to be false…shall be fined not more than $5,000 or imprisoned not more than two years or both.”

Maximum Insurable Loan (for Completion by HUD)
Total Per Line Item 8	$     
Less Disallowed Amounts	$     
Subtotal	$     
Mortgage Amount	$     
     % of Subtotal (Enter 85% if Acquisition; 100% if Refinanced)	$     
Amount Committed for Insurance (or amended amount)	$     
Maximum Insurable Loan (Enter the lower of A or B)	$     
By (Authorized Agent):      	Date:      

Instructions

In accordance with HUD Regulations, accurate records of all costs must be maintained and are subject to review by employees of HUD prior to the endorsement of the loan for insurance. The records must be in sufficient detail to permit the itemization of cost required by this form, including the Schedules below. Only those items of cost actually incurred by the Borrower will be allowed by HUD. (If the space allowed below for the Schedules of Cost is insufficient, continue the itemization on an attached sheet.)

Schedule A (Limited Rehabilitation – Item 2)

     	$     
     	$     
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Total	$     

Schedule B (Lender’s Fees – Item 4)

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Total	$     

Schedule C (Other – Item 7)

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Total	$     

Previous versions obsolete Page 4 of 4 form HUD-92205-OHF